Quiz 1 Flashcards
What substance is contained within the stem of the Mirena coil?
Levonorgestrel 52mg released at 20 micrograms per day.
List 3 contraindications to the use of this form of contraception.
Pregnancy Unidagnosed vaginal bleeding Previous ectopic pregnancy (relative CI) Past history of Pelvic Inflammatory Disease (relative CI) Structural cardiac abnormality Known HIV infection Genital malignancy Nulliparity (relative CI)
List two non-contraceptive benefits of the Mirena coil.
85% amenorrhoea at 6 months, leading to increase in Hb and serum ferritin
Decrease in risk of PID due to progestagenic effect on cervical mucous & endometrium
Lower ectopic risk compared to standard copper IUCD’s
Reduction in size of uterine fibroids
May be used as progestogen component of HRT
Describe your management of a patient who presents with the strings no longer visible at the external cervical os.
Ultrasound scan to check if IUS is intrauterine as a first investigation.
If intrauterine, consider whether it needs to be removed - does the patient wish pregnancy or need a change of IUS. If so, attempt removal with IUCD retriever, otherwise will need removal under anaesthetic or outpatient hysteroscopy.
If not intrauterine, AXR to check if it has perforated (as opposed to fallen down the toilet!). Then laparoscopy to retrieve.
How would you manage a patient using this form of contraception who presents with seven weeks amenorrhoea, tender breasts and nausea and vomiting in the morning?
Pregnancy test.
Transvaginal scan to detect if pregnancy intrauterine or ectopic (ectopic risk is 1/5 in IUS failures) - may need serial serum hCG’s if too early to descriminate.
Remove IUS if possible (miscarriage risk reduced from 50% to 20% following removal).
Explain risks if pregnancy continues with IUS in place - increased risk of preterm delivery and chorioamnionitis, and unknown teratogenicity risk of levonorgestrel release.
What is the main indication for ICSI?
Severe male factor infertility
What are three possible side effects of ICSI/IVF?
Multiple pregnancy
Ovarian hyperstimulation syndrome
Infection following TV USS-directed egg retrieval.
Increased risk of miscarriage
Increased risk of ectopic pregnancy
Psychological effects of intensive treatment with high failure rate
Increased risk of Y-chromosome abnormalities in male offspring conceived via this technique
What is the average quoted success rate?
About 20% per cycle - better for younger women and much worse for older. The main determinant is the age of the eggs used for IVF
What is the name of the governing body which oversees reproductive treatments?
Human Fertilisation and Embryology Authority (HFEA)
How may Down’s syndrome be detected antenatally? Name 2 screening tests and two diagnostic tests.
Screening: Serum screening (double or triple test) or first trimester nuchal translucency (NT) scan
Diagnosis: Amniocentesis or Chorion Villus Sampling (CVS)
Serum screening is carried out between 15-19 weeks and gives an indication if a woman is high or low risk.
NT screening in the first trimester will detect 80% of Down’s syndrome, but this is a first trimester screening test and 25% of Down’s pregnancies will spontaneously miscarry between 10 and 15 weeks. Thus in part NT screening may convert pregnancies that are destined to miscarry anyway into terminations of pregnancy.
What are the sensitivity and false positive rates for the most widely available screening method?
Sensitivity is 60%
False positive 5%
1 in 20 women who have serum screening will be told they are high risk and advised to undergo invasive testing - even though the vast majority of these babies will not have Down’s. It is important that this is conveyed in the counselling that takes place prior to serum screening.
What are the risks of miscarriage in confirming the diagnosis during the antenatal period?
CVS - 1-2%
Amnio - 0.5-1%
If a couple chose termination of pregnancy following prenatal diagnosis at 16 weeks gestation, what method would be used?
Medical termination of pregnancy with mifepristone & misoprostol most likely.
Dilatation & evacuation a possibility where local expertise exists up to 18 weeks gestation
How would a patient typically present with genital herpes?
Pain, superficial dysuria, vulval ulceration, discharge, retention of urine, apareunia.
How is the diagnosis of herpes made in practice and how may it be confirmed?
The diagnosis is made clinically but may be confirmed by viral culture from the lesions.
What is the treatment for genital herpes?
Antiviral treatment, e.g. Acyclovir 200mg 5x per day
Local anaesthetic gel (lignocaine 1%)
Broad spectrum antibiotics if ulceration severe to prevent secondary infection (eg. trimethoprim 200mg BD)
Topical acyclovir is not used for genital herpes
What needs to be discussed with a woman who presents with genital herpes for the first time at 37 weeks gestation?
Caesarean section to prevent overwhelming neonatal herpes. This is advised if the primary attack occurs any time after 34 weeks, as asymptomatic viral shedding is possible for some time after a primary attack.
If this was a secondary attack, caesarean section would be offered if lesion are present at the time of labour (although the risk of neonatal disease is much lower in this case).
It is also important to discuss screening for other genital infections and refer to GUM clinic for counselling & contact tracing.
When would you use a ring pessary/shelf pessary?
Genital prolapse (no extra marks for listing all the different types!) when unfit, unsuitable or patient declines surgery Pregnancy and the puerperium when prolapse occurs. The tissues will retract after delivery Prior to surgery to allow healing of a decubitus ulcer related to a procidentia
Give three side effects of using pessaries for prolapse
Discomfort
Retention of urine
Vaginal ulceration
Rarely carcinoma of the vagina
How often should pessaries be changed and why?
6-monthly to check for vaginal ulceration
